If you or someone in your family regularly uses brand name or specialty prescription medications, then you may already be paying attention to the recent media coverage around “copay accumulators.” Unfortunately, too many people are unaware of this big change coming their way. Let’s break down what a copay accumulator is and some commonly asked questions patients should be aware of.
Many insurance companies are adding copay accumulators to their insurance plans. Ignoring the fancy name, this means that those plans will no longer count manufacturer coupons of any kind toward the patient’s deductible. This includes manufacturer copay assistance programs, copay cards, and more traditional coupons that many patients use to afford brand name medications.
When the copay accumulator program’s impact is felt at the patient level later this year, a large majority of US workers will be affected, with the most widespread impact felt by individuals taking specialty drugs for chronic conditions. Many patients undergoing treatment for autoimmune conditions and cancer will also see drastic price changes when the new programs are implemented.
According to the Kaiser/HRET 2017 Employer Health Benefits Survey , about 8 out of 10 U.S. workers were required to meet a general annual deductible before most healthcare services were paid for by their insurance plan in 2017. Prescriptions were typically excluded from the deductible. However, one third of patients with high deductible plans are now faced with a separate prescription drug deductible, making them fully responsible for 100 percent of prescription costs until their deductible is met.
Patients whose health plans will no longer count manufacturer copay assistance (including copay cards and coupons) towards their deductibles will be left responsible for a much greater share of prescription costs.
For example, a medication which previously cost $7 may suddenly cost hundreds or even thousands of dollars because the maximum amount of copay assistance from the manufacturer was reached. Since the health plan will no longer allow the copay amounts to contribute to the patient’s deductible, the cost of the medication remains very high. The patient must now bear the full cost of the medication, which is often out of reach. The resulting financial strain may force some patients to reduce or discontinue their necessary prescription regimens.
Those taking brand name or specialty medications will face added pressure. Many chronically and terminally ill patients will soon find themselves and their families solely responsible for unaffordable prescription costs. The Los Angeles Times illustrates this with a story about a patient who takes the widely used drug Humira for her rheumatoid arthritis.
If you are affected by your insurance plan’s copay accumulator, there are still ways to lower the cost of your prescription drugs:
Experts expect many patients to feel the effects of these insurance changes before the end of 2018. Plan your spending now, so that you can make sure you can afford the medications you and your family need.
This post is part of our “Ask an Expert” blog series by Ken Majkowski, Pharm.D, the Chief Pharmacy Officer at FamilyWize. Ken brings more than 40 years of healthcare experience to the FamilyWize team, including 14 years of clinical pharmacy experience in retail, hospital, and home care. Read his full bio here.
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